Simultaneous Intracranial and Spinal Hemorrhage Following Tenecteplase Thrombolysis for ST-Elevation Myocardial...

Central nervous system (CNS) hemorrhage is a serious complication of intravenous thrombolysis. Tenecteplase, a fibrin-specific thrombolytic agent, has a lower risk of hemorrhage than other agents. We report the first documented case of simultaneous intracranial and spinal hemorrhage following intravenous administration of tenecteplase. A 55 year old Sri Lankan woman presented with ischemic chest pain and was diagnosed with an acute inferior ST-elevation myocardial infarction (STEMI). She was treated with oral aspirin, clopidogrel, atorvastatin, intravenous enoxaparin, tenecteplase (30 mg), and subcutaneous enoxaparin. Two hours after successful thrombolysis, she developed acute paraparesis with a sensory level at the fourth thoracic segment. A CT angiogram ruled out aortic dissection, but an MRI spine revealed a posterior extradural hemorrhage extending from the C4 to S1 vertebrae, and long segment of T2-weighted hyperintensity of the spinal cord with prominent gray matter involvement, consistent with compressive myelopathy. There was no evidence of pre-existing arteriovenous malformations, cavernoma, or coagulopathy. Additionally, a non-contrast CT of the brain performed due to headache revealed an intracranial hemorrhage in the left frontal lobe, although this was not associated with focal neurological deficits. Antiplatelet therapy and enoxaparin were discontinued. The patient developed cardiogenic shock and died 8 days later. In conclusion, tenecteplase can result in concurrent CNS hemorrhages even in the absence of vascular anomalies or coagulation defects. Clinicians should remain vigilant for both cranial and spinal hemorrhagic complications even with fibrin-specific agents like tenecteplase.